COLLEGE OF THE SISKIYOUS NURS 0951 HEAD TO TOE ASSESSMENT. Normal expected findings

Transcription

1 COLLEGE OF THE SISKIYOUS NURS 0951 HEAD TO TOE ASSESSMENT Assessment Normal expected findings GENERAL SURVEY *Introduction: Call patient by name, introduce self, shake hands, walk pt to exam room observing gait and posture Purpose Pt states reason for visit and time of appointment *Mental status Pt is alert and oriented (A&O) x4 to person, place, time, and event/situation Eye contact Pt makes good eye contact with nurse Posture Posture is erect *Gait Walking gait is steady *Appearance Pt shows no signs of distress/ dressed appropriately for the weather Hygiene Hair, nails, and clothing are clean and well groomed *Speech Speech is clear and appropriate Nutritional status Ask pt whether they follow any special diet, whether they drink water, assess whether weight is appropriate for height *Skin Skin is warm, dry and intact when shaking hands. No observable bruising, concerning moles, or other skin problems. Skin will be assessed as you move through each area. Tell pt that if they experience pain/discomfort at any time during the exam to let you know. HEAD AND FACE & EYES AND EARS Inspect hair for texture, distribution, and Hair should not be excessively oily or dry, quantity of hair even distribution on scalp, and no alopecia *Inspect symmetry and external characteristics Eyes and ears should be symmetrical with no of eyes and ears drainage Inspect eyelids, eyelashes and eyebrows No drooping of lids, full eyelashes & brows *Inspect sclerae, conjunctivae White sclerae, pink conjunctivae *Assess visual fields (CN II optic nerve) Pt will read at 20/20 Use a snellen eye chart for visual acuity or While looking straight ahead, pt will see your assess peripheral vision from behind pt fingers moving in from the side *Test pupillary response to light (with lights dimmed) and accommodation *Test extraocular eye movements H *(CN III oculomotor pupil constriction and EOM) *(CN IV- trochlear- EOM) *(CN VI abducens abducts the eyes with Pupils constrict with light and dilate when light is removed. They should do so consensually (e.g., when light is on one eye, the other should also constrict) When an item is brought close to the eyes, the pupils constrict. When the item is moved to a distance, the pupils dilate

2 2 accomodation) Hint: 3, 4 & 6 make your eyes do tricks (accommodation) The crossing of the eyes is called consensual convergence. PERRLA: Pupils are equal, round, reactive to light and to accommodation *Ask pt to open jaw and clench teeth as you palpate the masseter muscle. *(CN V trigeminal muscles for chewing) *Ask them to squeeze eyes shut tight, raise eyebrows, smile, and puff out cheeks *(CNVII facial taste in front 2/3 of tongue and facial expression) Hint: Think chewing a burger with Heinz 57 sauce. *Test hearing have pt cover one ear while you whisper a number in the other. Have them repeat the number *(CN VIII vestibulocochlear/auditoryhearing and balance) MOUTH AND PHARYNX Using a penlight: Inspect lips, buccal mucosa, gums, hard and soft palates, floor of the mouth for color and surface characteristics/dentition, oropharnyx: uvula, tonsils, posterior pharynx, mouth odor *Ask pt to swallow and say ah *(CN IX glossopharyngeal taste posterior 1/3 of tongue/tonsil & pharynx/swallowing) *Have pt. stick out tongue straight and then move from side to side *(CN XII - hypoglossal) NECK *(CN X vagus gland innervation/digestion/hr) *Inspect for symmetry and smoothness of neck and thyroid and palpate thyroid, ask pt. to swallow Inspect for right internal jugular venous distention with pt laying at 45 degree angle with head turned to the left *Test strength of head and neck and shoulder shrug with resistance With head not moving, eyes follow pen to all points of the H EOM intact (extra ocular movements) Jaw should open fully. You should feel the masseter muscle contract as they clench teeth Able to squeeze eyes shut tight, raise eyebrows, smile, and puff out cheeks Pt repeats the correct number Gums, tongue and oral mucosa are pink, moist and intact Teeth are intact and in good condition Tonsils of normal size and no halitosis With ah, there is symmetrical rise of the soft palate and uvula. Tongue is midline with no deviation and full tongue mobility Neck should be smooth and symmetrical and no obvious nodules on thyroid as the patient swallows and the thyroid moves up and down. Pt can swallow without difficulty and has intact gag reflex (if tested with a tongue depressor). No distention of the right IJV Pt can push head in all directions against resistance and shrug shoulders against

3 *(CN XI spinal accessory nerve innervates sternocleidomastoid/trapezius muscles/ controls shoulder and neck movements) *Palpate carotid pulses; only one side at a time! *Auscultate carotid arteries for bruits with bell of stethoscope resistance Pulses are strong and equal bilaterally No bruits Palpate tracheal position Trachea is midline UPPER EXTREMITIES Inspect and palpate shoulders, arms, and hands for hair distribution and muscle tone, skin and nail characteristics, temperature, edema Even hair distribution / no muscles atrophy/ no edema, warm, dry, intact skin/ clean healthy nails *Assess capillary refill of one finger on each Capillaries refill with blood within 2-3 hand by blanching and releasing seconds *Palpate brachial and radial pulses Pulses are strong and equal bilaterally *Assess range of motion wrists (rotation), Full range of motion bilateral upper elbows (flexion/extension), shoulders extremities (circumflexion) *Assess strength of grip and against resistance Strong grip and able to push against resistance FEET AND LEGS *Inspect and palpate hips, thighs, calves and feet for hair distribution and muscle tone, skin and nail characteristics, temperature, edema *Assess capillary refill of one toe on each foot by blanching and releasing *Palpate femoral, popliteal, posterior tibialis and dorsalis pedis pulses *Assess range of motion hips (abduction/adduction/flexion and extension), knees (flexion and extension) ankles (circumduction), and feet (plantar flexion and dorsiflexion) *Assess strength of thighs, lower legs, and feet against resistance SPINE Ask pt to bend over as though touching their toes, but only as far as is comfortable: Palpate spinal processes and place hands on scapulae and hips Even hair distribution / no muscles atrophy/ warm, dry, intact skin/ clean healthy nails/ no edema Capillaries refill with blood within 2-3 seconds (Gloves when assessing the femoral pulses) Pulses are strong and equal bilaterally Full range of motion bilateral lower extremities Strong and able to push against resistance No curvature of the spine or masses and scapulae and hips are level bilaterally no kyphosis, scoliosis, or lordosis 3

4 4 CHEST AND LUNGS Inspect skin and chest expansion Skin is intact and even chest expansion Inspect respiratory effort/depth, rhythm, and Breathing is nonlabored, even rhythm, no any pulsations visible pulsations *Palpate chest wall No tenderness, crepitus, or palpable pulsations *Auscultate systematically (bronchial, Lung sounds are clear in all fields bronchovesicular, vesicular) for breath sounds Inspect skin of posterior thorax and spine Skin is intact *Palpate thorax No tenderness or crepitus *Auscultate systematically (bronchial, Lung sounds are clear in all fields bronchovesicular, vesicular) for breath sounds HEART *Auscultate systematically for heart sounds: No murmurs aortic valve (2 nd intercostal space (ICS) right Aortic and pulmonic valves S2 is louder than sternal border), S1, Erbs point S1 and S2 are equal, tricuspid pulmonic valve (2 nd ICS left sternal border), and mitral valves S1 is louder than S2. The ERBS point (3 rd ICS left sternal border), mitral valve is the point of maximal impulse tricuspid valve (4 th ICS left sternal border), and where you auscultate an apical heart rate for mitral valve (5 th ICS left midclavicular line) one full minute. ABDOMEN *Ask pt when was their last bowel movement and any problems with the stool *Inspect skin and contour *Auscultate all quadrants for bowel sounds (RLQ, RUQ, LUQ, LLQ) If no bowels sound are heard, auscultate at least 5 min in each quadrant to confirm the absence of bowel sounds Auscultate the aorta and renal & iliac arteries Pt verbalize recent BM no diarrhea/constipation/blood/change in bowel habits Skin is intact, no distention or visible masses, no herniation or pulsations Positive bowels sounds in all four quadrants (a minimum of 5 gurgles per quadrant within one minute) No bruits using the bell of the stethoscope Percuss all quadrants for tone Dull over organs and fecal filled bowels, tympanic (air) over stomach and gas filled bowels, and flat over bone *Lightly palpate all 4 quadrants 2 cm depth Nontender *Deeply palpate all 4 quadrants 4 cm depth Soft nontender, nondistended or no masses *Identify organs in appropriate quadrants RLQ appendix & McBurney s Point/ ascending, under the diaphragm is the transverse colon and LLQ descending colon and sigmoid colon RUQ liver/gallbladder LUQ pancreas and spleen *Assess urinary function Clear, yellow, odorless urine/ no pain, frequency, burning, nocturia, or blood.

5 5 HEALTH PROMOTION QUESTIONS Men: monthly self-chest and self-testicular exams, annual prostate exam after 40, colonoscopy after 50 (every 10 years) Women: monthly self-breast exam, annual gynecologic exam, menses assessment, annual mammogram after 40, colonoscopy after 50 (every 10 years)